2006 February » Medicare and Medicaid News

Stroke, Vol. 32, No. 6. (June 2001), pp. 1279-1284.

BACKGROUND AND PURPOSE: The goals of the present study were to estimate the prevalence of acute impairments and disability in a multiethnic population of first-ever stroke and to identify differences in impairment and early disability between pathological and Bamford subtypes. Associations between impairments and death and disability at 3 months were identified. METHODS: Impairments that occur at the time of maximum neurological deficit were recorded, and disability according to the Barthel Index (BI) was assessed 1 week and 3 months after stroke in patients in the South London Stroke Register: RESULTS: Of 1259 registered patients, 6% had 1 or 2, 31.1% had 3 to 5, 50.6% had 6 to 10, and 10.6% had >10 impairments. Common impairments were weakness (upper limb, 77.4%), urinary incontinence (48.2%), impaired consciousness (44.7%), dysphagia (44.7%), and impaired cognition (43.9%). Patients with total anterior circulation infarcts had the highest age-adjusted prevalence of weakness, dysphagia, urinary incontinence, cognitive impairment, and disability. Patients with subarachnoid hemorrhage had the highest rates of coma. Patients with lacunar stroke had the high prevalence of weakness but were least affected by disability, incontinence, and cognitive dysfunction. Blacks had higher age- and sex-adjusted rates of disability in ischemic stroke (BI <20, odds ratio 2.76, 95% CI 1.47 to 5.21, P=0.002; BI <15, odds ratio 1.8, 95% CI 1.45 to 2.81, P=0.01) but impairment rates similar to those of whites. On multivariable analysis, incontinence, coma, dysphagia, cognitive impairment, and gaze paresis were independently associated with severe disability (BI <10) and death at 3 months. CONCLUSIONS: The extent of these findings indicates that an acute assessment of impairments and disability is necessary to determine the appropriate nursing and rehabilitation needs of patients with stroke.
ES Lawrence, C Coshall, R Dundas, J Stewart, AG Rudd, R Howard, CD Wolfe

Stroke, Vol. 32, No. 1. (1 January 2001), pp. 107-112.

Background and Purpose--The purpose of this study was to assess the effects of stroke involvement of primary and secondary hemispheric motor systems and corticofugal tracts on arm and hand recovery. Methods--Forty-one patients participating in an inpatient stroke rehabilitation database, admitted 17+/-2 (SEM) days after initial unilateral hemispheric ischemic stroke, with neuroimaging studies performed >48 hours after stroke and with minimal upper limb (UL) movement (admission Fugl-Meyer UL motor scores [<=]9; normal score, 58) were studied. Patients were divided into 3 groups according to their UL discharge Fugl-Meyer score: 0 to 9, no/poor recovery; 10 to 18, well-defined flexion-extension synergies; and >18, synergies+isolated movements. Lesions affecting the following structures were recorded: primary motor cortex, premotor area, supplementary motor area, anterior half of the middle third of corona radiata (secondary motor efferents), posterior half of the middle third of corona radiata (primary motor efferents), genu, anterior and posterior limbs of the internal capsule (PLIC), basal ganglia, and thalamus. chi2 Analysis and ANOVA were used to study the significance of stroke location on UL motor recovery. Results--The effect of involvement of primary, premotor, or supplementary motor areas on motor recovery did not reach statistical significance. Patients with purely cortical stroke were likely to recover UL isolated movement (3 of 4) compared with purely subcortical (1 of 17) or mixed cortical-subcortical stroke location (2 of 20) (P=0.009). Of those with cortical, subcortical, or mixed cortical plus subcortical lesions sparing the PLIC, 5 of 13 recovered isolated UL movement (P=0.01). Only 1 of 28 patients with involvement of the PLIC plus adjacent corona radiata, basal ganglia, or thalamus recovered isolated UL movement (P=0.01). Patients with small lacunar strokes affecting only the PLIC did not have sufficient motor deficits 2 weeks after stroke to meet inclusion criteria. Conclusions--The probability of recovery of isolated UL movement decreases progressively with lesion location as follows: cortex, corona radiata, and PLIC. This is consistent with our current understanding of redundant cortical motor representation and convergence of corticofugal motor efferents as they pass through the corona radiata to the PLIC.
Fatima Shelton, Michael Reding

Stroke, Vol. 34, No. 6. (1 June 2003), pp. 1553-1566.

Background-- The precise mechanisms of and biological basis for motor recovery after stroke in adults are still largely unknown. Reorganization of the motor system after stroke as assessed by functional neuroimaging is an intriguing but challenging new field of research. Provocative but equivocal findings have been reported to date. Summary of Review-- We present an overview of functional neuroimaging studies (positron emission tomography or functional MRI) of motor tasks in patients recovered or still recovering from motor deficit after stroke. After a brief account of the connectivity of motor systems and the imaging findings in normal subjects, the literature concerning stroke patients is reviewed and discussed, and a general model is proposed. Conclusions-- Both cross-sectional and longitudinal studies have demonstrated that the damaged adult brain is able to reorganize to compensate for motor deficits. Rather than a complete substitution of function, the main mechanism underlying recovery of motor abilities involves enhanced activity in preexisting networks, including the disconnected motor cortex in subcortical stroke and the infarct rim after cortical stroke. Involvement of nonmotor and contralesional motor areas has been consistently reported, with the emerging notion that the greater the involvement of the ipsilesional motor network, the better is the recovery. This hypothesis is supported by the enhanced activity of the ipsilesional primary motor cortex induced by motor training and acute pharmacological interventions, in parallel with improved motor function. Further longitudinal studies assessing the relationships between such changes and actual recovery, as well as manipulating such changes by rehabilitation or pharmacological maneuvers, should provide further information on these fundamental questions. This review closes with some perspectives for future research.
Cinzia Calautti, Jean-Claude Baron

Medicare and Medicaid News

Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population.

Effect of Lesion Location on Upper Limb Motor Recovery After Stroke

Functional Neuroimaging Studies of Motor Recovery After Stroke in Adults: A Review